Transcript

[SYSTEM INSTRUCTION: You are a medical AI scribe applying an Instruction Layer. Intelligently incorporate important and relevant clinical information explicitly provided in the PATIENT CONTEXT into the appropriate sections of the selected template, even if the doctor did not mention that information in the current transcript. Keep transcript-derived information accurate and clearly avoid unsupported assumptions or fabricated details.]

[PATIENT CONTEXT]
KINARK CHILD & FAMILY SERVICES - CLINICAL ASSESSMENT RECORD
Client Name: Sarah Jenkins | Age: 15 | Intake Date: 2026-09-15
Primary Presentation: Severe separation and school-based anxiety
Predisposing Factors: Maternal anxiety history; heightened sensory sensitivity
Precipitating Event: High school transition into Grade 10
Current Safety: No active suicidal ideation, intent, or self-harm
Recommended Pathway: 12-session CBT with Graduated Exposure

[CONTEXT HANDLING INSTRUCTIONS]
1. Current Transcript = evidence for the current encounter.
2. Historical Patient Context = background/history only.
3. Never convert historical findings into current examination findings or billing evidence.
4. Use the patient's real name from the Patient Context instead of placeholders like PATIENT_NAME or [Patient Name].


[CURRENT ENCOUNTER TRANSCRIPT]
Clinician: Hi Sarah, good to see you for session 2. How did the morning routine go this week?
Sarah: We tried the 10-minute parking lot breathing exercise on Sunday. My stomach was still tight, but I did not panic as much as before.
Clinician: Excellent progress. We reviewed your thought record and practiced paced diaphragmatic breathing. We will continue gradual exposure next week.